Sir,

We thank Dr Pandey and Mr Scott for their interest in our article. We support their observations drawing attention to the danger of incorrectly mounted Luer lock intra-ocular cannulae as a potential risk. Following notification of this case report, the National Reporting and Learning (NRLS) database at the National Patient Safety Agency (NPSA) was searched for any similar patient safety incidents. On the NRLS database, three more similar incidents and one near miss were retrieved. These cases along with the example reported by Pandey and Scott share a common consequential theme. This is of intra-ocular cannulae – such as Rycroft, hydro-dissection, or wound hydration cannulae – ‘exploding’ from syringes during cataract surgery. While root cause of events is not confirmed, failure to correctly engage Luer lock cannulae appears to be an issue. As such it might be best considered as ‘user error’ and is a patient safety incident, rather than a device failure. It is prudent to highlight device incidents to the Medicines and Healthcare products Regulatory Agency (MHRA) so that any device products concerned might be investigated further. We have now brought this matter to their attention.

We support the publicity of patent safety incidents so that the learning arising and any solutions emerging can be shared. Ophthalmic staff should be aware of this specific risk with mounting Luer lock syringes. We applaud the practice of Pandey and Scott of checking secure engagement of Luer lock mounted cannulae before their introduction into the eye. We commend the reporting of all patient safety incidents in both NHS and in independent sector care.